Interpreting Biopsy-guided Antimicrobial Therapy in Diabetic Foot Osteomyelitis: Is Biopsy Method Really the Key?

To the Editor—We read with great interest the recent randomized controlled trial by Lagrand et al evaluating bone biopsy–guided versus ulcer bed biopsy–guided antibiotic therapy in diabetic foot osteomyelitis (DFO). This double-blind, randomized study undoubtedly enriches the available yet limited information on a topic of great clinical importance and frequently discussed in medical practice. Nevertheless, we would like to address several aspects that we believe are important for the interpretation and applicability of the reported results. First, further characterization of the study population would have strengthened the clinical relevance of the findings. Detailing the types of ulcers, and offering a precise anatomical location are essential, as these factors are known to influence microbiology, treatment response, and prognosis 1. In addition, the manuscript does not clearly specify whether infections were predominantly monomicrobial or polymicrobial, nor does it fully describe patients' comorbidities beyond diabetes, such as peripheral arterial disease, chronic kidney disease, or prior amputations, which are key determinants of outcome 2. Authors do not clarify whether patients were managed entirely as outpatients or required hospitalization; therefore, the manuscript does not reflect disease severity, and this may influence generalizability of the study's conclusion 3.